Conservative Management for Retained Products of Conception in Late Pregnancy

Abstract

This retrospective study aims to compare the early manual removal of placenta (MROP) and conservative management of retained products of conception (RPOC) after 34 weeks of gestation. Nineteen cases underwent MROP within 24 h of delivery, of which nine patients had no symptoms requiring emergent treatment. These 9 patients (group M) were compared with 22 patients who were treated conservatively (group C). Massive bleeding was observed in 5 (56%) patients in group M and 11 (50%) patients in group C, with no significant difference in frequency. However, the lowest hemoglobin level within 72 h after massive bleeding was lower in group M (median: 6.7 vs. 7.7 g/dL, p = 0.029), suggesting that massive bleeding occurred in a short period of time. On the other hand, a retained placenta was observed in four patients in group M after the MROP; however, the placenta disappeared more quickly than in group C (median; 1.0 vs. 99.0 days, p = 0.009). In group C, all bleeding and infection occurred within 60 days of delivery, including heavy bleeding in six cases during the placental-extraction trial. Human chorionic gonadotropin in group C fell below the measurable threshold at a median of 67 days postpartum. In conclusion, for RPOC without urgent symptoms, early MROP and conservative treatment have their advantages and disadvantages. Randomized controlled trials are needed to determine which of those treatments is superior.

Keywords: human chorionic gonadotropin (hCG); postpartum hemorrhage; retained products of conception (RPOC).

Figure 1

Flowchart of the present study. RPOC: retained products of conception. MROP: manual removal of placenta.

Figure 2

(A). Clinical courses of 19 cases with placental removal within 24 h after delivery. The numbers in “Size and blood flow of RPOC” indicate the size of RPOC (mm). The numbers in “After” and “Disappearance of RPOC” indicate the duration from delivery to the onset of the events (days). RPOC, retained products of conception. (B). Clinical courses of 22 cases with conservative management. The numbers in “Size and blood flow of RPOC” indicate the RPOC size (mm). The numbers in “Events” and “Disappearance of RPOC” indicate the duration from delivery to the onset of event (days). RPOC: retained products of conception.

Figure 3

Representative images of RPOC cases with conservative management. (A) Case 23: Contrast-enhanced CT showed strongly contrast-enhanced RPOC in the arterial phase (postpartum day 10). Arrow shows RPOC. (B–F) Case 37: Serial changes in contrast-enhanced MRI during conservative management. (B) Sagittal T2WI showed an RPOC in the uterus. The RPOC size was 72 × 42 × 49 mm (postpartum day 3). (C) Sagittal contrast T1WI demonstrated strongly contrasted RPOC (postpartum day 3). (D) Sagittal T2WI showed RPOC in the uterus, whose size became smaller. The RPOC size was 22 × 17 × 15 mm (postpartum day 22). (E) Sagittal contrast T1WI still demonstrated strongly contrasted RPOC (postpartum day 22). (F) MRI did not detect RPOC (postpartum day 64). Ultrasound showed RPOC of 8 mm on postpartum day 87. On postpartum day 102, hysteroscopy showed that the RPOC was 10 mm, and on postpartum day 201, it was finally confirmed that the RPOC had disappeared. CT: computed tomography; RPOC: retained products of conception; MRI: magnetic resonance imaging; T2WI: T2-weighted imaging; T1WI: T1-weighted imaging.

Figure 4

The cumulative incidence rate of events in group C (RPOC cases with conservative management). The horizontal and vertical axes represent the duration from delivery to the onset of the events (days) and the incidence rate (%), respectively. Red lines and blue lines show cumulative incidence rates of heavy bleeding (A), blood transfusion (B), UAE (C), and infection (D) in 22 cases with conservative management of RPOC and in 16 cases without placental extraction trial during conservative management. RPOC: retained products of conception; UAE: uterine artery embolization; D&C: dilatation and curettage.

Figure 5

The cumulative incidence rate of events in Group M and Group C. The horizontal and vertical axes represent the duration from delivery to the onset of the events (days) and the incidence rate (%), respectively. Red lines and blue lines show cumulative incidence rates of heavy bleeding (A), blood transfusion (B), UAE (C), and infection (D) in Group M (n = 9) and Group C (n = 22). RPOC: retained products of conception; UAE: uterine artery embolization.

Figure 6

Univariate analysis between group M and group C at heavy bleeding. RCC: red cell concentrate; FFP: fresh frozen plasma.

Figure 7

The cumulative rate of RPOC resolution. The horizontal and vertical axes indicate the duration from delivery to resolution (days) and the cumulative incidence rate (%), respectively. Arrows and arrow head indicate the timing of MROP and TCR, respectively. RPOC: retained products of conception; MROP: manual removal of the placenta; TCR: transcervical resection.

Figure 8

Serial changes in serum hCG. The horizontal and vertical axes indicate the duration from delivery to the measurement date (days) and the serum hCG level (IU/L), respectively. (A,B) RPOC cases delivered after 34 weeks of gestation. (A) Cases without UAE. (B) Cases with UAE. Arrows show the date on which UAE was performed. (C,D) RPOC cases delivered at less than 20 weeks of gestation and did not undergo UAE. (C) Cases with serum hCG half-life of less than 10 days. (D) Cases with serum hCG half-life of more than 10 days. RPOC: retained products of conception; UAE: uterine artery embolization; hCG: human chorionic gonadotropin.